Inflammatory diseases and role of

dietFarhan Tahir MD, FACR

Consultant RheumatologistRheumatic Disease Associates, Ltd.

Abington Memorial HospitalDoylestown Hospital

What is Inflammation?

Inflammation is immune system’s response to injury or infection

Autoimmune disease are result of an unhealthy disordered immune system

Inflammation results in pain, swelling, heat and redness of joints and tendons

Role of inflammatory in arthritis

Inflammation is a cascade of biological process which leads to production of harmful chemicals ; cytokines

Cytokines detrimental to body are (IL)-1, IL-6, tumor necrosis factor (TNF)-alpha, gamma interferon (INF-gamma)

Cells produce reactive oxygen species (ROS) harmful to cartilage and joint structures leading to destruction

Chronic Inflammatory Diseases

More than 40 distinct autoimmune diseases

24 million Americans are affected (NIH Autoimmune Disease Coordinating Committee, June 2005)

Examples: Asthma, Cohn's disease, Rheumatoid arthritis, SLE, Celiac disease

Examples of chronic conditions with an inflammatory component include atherosclerosis, obesity, diabetes, cancer, and perhaps even Alzheimer’s disease

Evolution of Nutrition Primitive humans; wild game or

vegetarian Refining; loss of fiber and

micronutrients Western diet had 75% decline in

fiber, 5 fold increase in sugar and four fold increase in fats

Our hunter-gatherer ancestors consumed equal amounts of omega-6s and omega-3s

Todays’s diet has been estimated to contain 14-25 times as much omega-6 as omega-3 fat

Overfed and Undernourished

“Snack” and “fast” food: high fat, high sugar

Western diet leads to “Overfed and undernourished” state

Increase weight, decreased essential nutrients

60% Americans: high waist/hip ratio (WHR) and BMI

Alarming rates of diabetes, cancer, metabolic syndrome, heart and autoimmune diseases are linked to western diet

Western diet; Standard American Diet

(SAD) High in red and processed animal

meats, saturated fats, trans fats, sweets, desserts, fired food and refined grains and low in fiber

Low in low-glycemic carbohydrates, fruits, vegetables, fish and legumes

12 yr relative risk of colon cancer 1.46, 8 yr heart disease risk 64%, 1.3 RR of all cause mortality

Nutrition and Autoimmunity

Inflammation and immune dysfunction starts in the intestinal track

Presence of antibodies of intestinal bacteria like Proteus mirabilis have been linked to RA

Lower antigen load, intake of vegetables, fruits and dietary vitamin C reduce risk, e.g. Norwegian and Mediterranean diets

High Glycemic Carbohydrates

Negative impact on lipid and sugar metabolism

Doubles reactive oxidative radicals production; increases peripheral vascular disease

Depressed immunity and impairs white blood cell function

Autoimmunity : Crohns disease, Rheumatoid arthritis

Impact of unhealthy Fats

Trans and saturated fats are associated with depressed immunity

Doubles risk cataract Atherosclerosis Heart arrhythmias Cancers Decreases bone mineral density

osteoporosis

Arthritis and Nutrition

RA is a common autoimmune type of arthritis

1 in 100 persons, affects women more than males

Cause is combination of genetic makeup and environmental cause or infection

Main stay of treatment is allopathic medications

Use of anti inflammatory diet and complementary therapy can be of immense help

Osteoarthritis and Nutrition

It is degenerative type of arthritis, most common form of arthritis

Affects weight bearing joints; knees, hips also affects hands and spine

Loss and damage of cartilage and joint structure

Leads to loss of smooth gliding, pain and swelling, improves with rest

Weight loss, conditioning exercises with anti inflammatory nutrition has great potential

Role of diet in arthritis

Elimination Anti inflammatory approach Anti oxidants Probiotics Herbal supplements

Elimination diet for food triggers

Arthritis linked to food sensitivities Dairy products, wheat, and

nightshade vegetables (bell pepper, eggplant, tobacco, tomato, and white potato) may be culprits

Eliminating and gradual re-introduction of the culprit foods will allow identification

High intake of coffee is linked to increased risk of RA, 4 or more cups/day

UltraInflamX® is an anti-inflammatory medical food

Anti-inflammatory approach

Diet and supplements Mediterranean diet; vegetables,

whole grains, nuts Vitamin B6 and folic acid Omega-3 , EPA, DHA Anti oxidants Probiotics Herbal, Spices Bone supplements: Vitamin D,

Calcium, Boron

Essential fatty acids

Humans are unable to synthesize the fatty acids linoleic acid and linolenic acid

Must be obtained through the foods Both of these fats are

polyunsaturated, meaning they will be liquid rather than solid at room temperature

Linoleic acid belongs to the family of omega-6 fats and is readily available

Sources of Omega 3

Sources of Omega 6

Polyunsaturated fatty acids

Omega 3 Fatty acids Remember EPA and DHA Produce resolvin which is anti

inflammatory Clinical trials in RA, Lupus and

Ankylosing spondylitis have proven benefit

Improved patient reported pain, morning stiffness, number of painful and tender joints

Average recommended dose , EPA 30mg/kg, DGA 50mg/kg or total 3.5g/day

Omega 6 versus Omega 3

In general, omega-6 fats tend to promote inflammation, constriction of the blood vessels, and formation of blood cell clots

Omega-3 fats are anti-inflammatory, relax the blood vessels, and protect against blood cells aggregating together into clots

Fat Guidelines

Use coconut oil, canola, or olive oil (extra virgin is best) for cooking

Make your own salad dressing with extra virgin olive oil, and red wine or balsamic vinegar

Flax seeds and oil, sardines, ocean salmon, and walnuts

Use a daily supplement of 1-4 grams of high EPA/DHA fish oils

Decrease pro inflammatory foods

Trans fats, arachadonic acid and sugar may promote inflammation, so an anti-inflammatory diet is low in trans fats, arachadonic acid and sugar.

Commercial meat and eggs are rich sources of arachidonic acid;

Omega-3 eggs and pasture-fed beef have lower amounts of arachidonic acid.

Fats for life Healthy choices Extra virgin olive oil Expeller-pressed organic

canola oil Nuts, Walnut and hazelnut oils

in salads Avocados Seeds - freshly ground

flaxseed. Cold water fish Dark roasted sesame oil as a

flavoring for soups and stir-fries

Superior quality supplements

Role of Omega 6 in Rheumatoid arthritis

Omega 6: LA and ARA driven chemicals are pro- inflammatory, role confirmed in RA

LA: vegetable oils; corn, sunflower, safflower

ARA: animal products, abundant in beef (grain fed), conventionally produced eggs

GLA : has anti inflammatory properties, sources, Oils of evening primrose, borage and black currant

Dose 1.5-3g/day

Protein Guidelines Have protein with each meal and

snack if possible Limit red meat or eliminate it unless

it is free-range, grass-fed beef or lamb

Avoid charring/browning proteins/meats

Use free-range eggs for protein but avoid browning the eggs

Avoid lunch meats that have sodium nitrate or nitrites, consider nitrite free turkey

Protein Guidelines Use walnuts as snack, good protein

and omega-3 fats source Use mixed nuts and seeds (pumpkin,

sunflower) Consider nut butters ; almond,

cashew, macadamia Soy products good sources of protein Organic milk products (milk, cheese,

and yogurt) For milk substitutes, use soy, rice,

almond, or oat milk

Add Color to your plate

Flavonoids and carotenoids, antioxidant and anti-inflammatory activity

Lightly cooked dark leafy greens (spinach, collard greens, kale, Swiss chard)

Cruciferous vegetables (broccoli, cabbage, brussels sprouts, kale, cauliflower)

Carrots, beets, onions, peas, squashes, sea vegetables and washed raw salad greens

BEANS & LEGUMES

Rich in folic acid, magnesium, potassium and fiber

They are a low-glycemic-load food 1-2 servings per day (one serving is equal

to ½ cup cooked beans or legumes) Beans like Anasazi, black, chickpeas,

black-eyed peas and lentils Well-cooked either whole or like hummus

New Life Eating Plan (NLEP)

Diet for OA sufferers Nutrient-dense; hypoallergenic;

nightshade-free; yeast-free; high in alkalinity, fiber, essential fatty acids, and phytonutrients (e.g., berries, cherries, and green and yellow vegetables); and low in land-animal products.

Elimination of possible food allergens, stabilization of insulin levels, and correction of leaky gut and imbalanced bacterial flora in the bowel

Antioxidants

Inflammation leads to reactive oxygen radicals

Oxidative damage to the joint and cartilage destruction

Antioxidants defend against this process

Increased anti oxidants consumption may prevent or relieve pain in RA and OA

Vitamin E & C Selenium, Quecertain, Resveratrol

Top Anti oxidants1 cup: Numbers refer to ORAC

(Oxygen Radical Absorbance Capacity) values

Wild blueberry, 13427 Blueberry, 9019 Cranberry, 8983 Artichoke hearts, 7904 Blackberry, cultivated, 7701 Raspberry, 6058 Strawberry, 5938 Sweet cherry, 4873

Fruit as a healthy snack

Fruits are rich in flavonoids and carotenoids with both antioxidant and anti-inflammatory activity

3-4 servings per day Raspberries, blueberries,

strawberries, pomegranates blackberries, cherries, all lower in glycemic load than most tropical fruits

Vitamin E

Animal studies showed less arthritis with antioxidants

Framingham study showed an associated of reduced risk of OA and vitamin E intake

Pain controlling effects Mixed tocopherols, gamma type is

most potent Daily dose 600-800IU

Vitamin C Positive effects of vitamin C on health

of immune system Reducing risk of Rheumatoid arthritis

and OA May reduce risk of cartilage and

progression A study of 640 patients showed three

fold decrease in OA progression An Australian study found an inverse

relationship in incidence of OA and intake of vitamin C and fruits

A study stated high risk of RA with lowest intake

Resveratrol (grape extract)

Present in various fruits especially skin of grapes

Potent antioxidant properties protects cells

Has anti inflammatory and prevents cartilage cell death

Several animal studies are proven helpful and many human studies are underway

Selenium

The mineral selenium chelates mercury in the body, and the chelated selenium-mercury complex is eliminated in the stool.

Thus consumption of one or two Brazil nuts (a rich source of selenium) with a meal of fatty fish is advisable

Vitamin D

Vitamin D has a vital role in regulation immune system and association with RA, SLE and OA

Vitamin D receptors are present on the immune cells, synovial and cartilage cells

Framingham data suggests 3x risk of progression of OA with lower intake

Another study showed lower levels associated with cartilage loss, increased risk of hip OA

Vitamin D

Iowa women health study found lower levels of vitamin D associated with higher risk of developing RA, more tender, swollen joints and HAQ scores

Nurses health survey linked higher level of vitamin D with healthier lifestyles

Dose: Vitamin D3- 2000-4000IU a day

Vitamin K

Important bone regulator A recent study showed that low

levels of vitamin K1(phylloquinone) associated with an increased prevalence of OA hand and knee

Framingham study found lower levels associated with x-ray findings of OA hands and knees

Vitamin K2 is also helpful in osteoporosis

Dietary deficiency

Lower levels of B6 and folate found in red blood cells of RA patients

Low B6 is also associated with homocysteine levels which is associated with heart disease in RA

Level of folic acid is low since disease modifying drug competitively inhibit its absorption

Recommended dose B6 50mg, folic acid 1mg

Vitamin B6 and folic acid

Probiotics Probiotics are live microorganisms,

also known as “friendly bacteria,” Help maintain the natural balance of

organisms (microflora) in the human gut

Vital for a healthy immune system, protect against disease-causing microorganisms,

The most well- known probiotics are Lactobacillus acidophilus, occurring naturally in yogurt, and Bifidobacterium

Natural supplementsGlucosamine

Synthesized from chitin in shellfish exoskeletons

Hypothesized to rebuild damaged cartilage by stimulating the synthesis and inhibiting the degradation of glycosaminoglycans and proteoglycans

Glucosamine sulfate is absorbed and distributed to the joint tissues

It has anti-inflammatory and anabolic properties

1500 mg, best to dose glucosamine once a day

Natural supplements Chondroitin

Chondroitin contributes to the resilience and elasticity of cartilage

It is a building block for the formation of the joint matrix structure

Bovine or shark cartilage. Animal studies suggest functions as an anti-inflammatory agent

Trials showed variable results, combination seem to work better, delayed progression

120omg/day, good safety data

Natural supplementsMSM

Being popularly market for arthritis, found in may foods we eat, effectiveness needs confirmation

Clinical data is still inconclusive for effectiveness, but combination of glucosamine and Chondroitin is more effective than used alone

Dose is 1500mg, up to 3-4 times/day No toxicity issues reported

Natural supplementsSAMe

SAMe has scientific evidence to support its effectiveness in double blind clinical trials

Has anti inflammatory properties, compared to Naproxen, Piroxicam and Celebrex

Typical dose is 200-400mg 3-4x/day Works slowly and has been also

found to have beneficial effects for depression and fibromyalgia

Spice up your taste buds

HEALTHY HERBS & SPICESWhy: Use these herbs and spices

generously to season foods. Turmeric and ginger are powerful, natural anti-inflammatory agents

Healthy choices: Turmeric, curry powder (which contains turmeric), ginger and garlic (dried and fresh), chili peppers, basil, cinnamon, rosemary, thyme

Herbal or Botanicalapproach

Avocado/Soybean Unsaponifiables

Ashwagandha Boswellia Bormelain Curcumin Cats claw Devil’s claw

Evening Primrose Oil

Ginger Garlic Rose hip Thunder God

Vine Willow

Ginger

May have efficacy in RA by inhibiting inflammatory chemicals (prostaglandins)

Dosage, root 1g, 2-3x/day or as tea Avoid if have history of gall bladder

stones

Turmeric (Curcumin)

Clinical trial has shown efficacy similar to Nsaids

Powdered root, 500mg-1000mg, 2-3x/day

Avoid if risk of bleeding, GI intolerance and impaired fertility

Boswellia

Inhibits the synthesis of pro inflammatory chemicals

It is suggested to have efficacy in OA A study of 30 patients with knee OA

found improvements in pain and walking distance

Avocado soybean oil extract

Recent studies have showed that ASU has promising beneficial role in OA hips and knees

It has effects on type 2 collagen synthesis

4 major clinical studies suggested benefit with 6 months of use

No major adverse effects noted Dose: 300m/day for 3-6 months

Thank You

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2. Calder PC: Polyunsaturated fatty acids and inflammation. Prostaglandins Leukot Essent Fatty Acids 2006; 75(3): 197-202. (PubMed)

3. Scott A, Khan KM, Roberts CR, Cook JL, Duronio V: What do we mean by the term "inflammation"? A contemporary basic science update for sports medicine. Br J Sports Med 2004; 38(3): 372-80. (PubMed)

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